Fundamentals of Nursing and Midwifery 2e

Chapter 15 Assessing

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Identifying data to be validated Because validation of all data is neither possible nor neces- sary, nurses and midwives need to decide which items need verification. For example, data need to be verified when there are discrepancies. For example, a person may tell you they are fine and have no concerns, but you note that they demonstrate tense body musculature and seem curt in their responses. When there is a discrepancy between what the person is saying and what you are observing, validation is necessary to determine accuracy. Validation in this instance may take the form of you saying: ‘You tell me you feel fine, but right now your body and behaviours are telling me something else. Tell me more about this.’ Data also need verification when they lack objectivity. For example, you suspect that the person hears in one ear but does not seem to hear well in the other. You should val- idate the data before proceeding and determine whether the person does indeed have a hearing problem. Suspicions are not objective. In this instance, the person’s hearing in both ears needs to be tested. Speaking towards the suspected better hearing ear, you explain: ‘It seems to me that you hear better out of one ear than the other. I would like to test this. I’ll bring a watch slowly towards your right ear first and then towards your left. Please look straight ahead and tell me when you first hear the watch ticking.’ You then record how far the watch was from each ear when the person first heard it ticking. Identifying cues and making inferences In Chapter 14, the processes of critical thinking and clin- ical reasoning that include collecting cues and making inferences is explained. Nurses and midwives use this lan- guage of cues and inferences to describe the process of validation. The subjective and objective data you identify (the person does not respond when I speak to her on her left side) is a cue that something may be wrong. The judgement you reach about the cue (the person’s hearing may be impaired on her left side) is an inference . Until you check the person’s hearing you cannot be sure that your inference is correct. Inferences should be validated through the gathering of evidence and this can be under- taken in multiple ways: • Physical examination, using proper equipment and procedure (you may need to have an expert confirm your findings) • Clarifying statements (‘You said this is not a problem, but I sense you may still be worried.’) • Sharing your inferences with other members of the team • Checking your findings with research reports. See Figure 15-2 for an illustration of validating infer- ences. You may validate data as they are collected or at the end of the data-gathering process. When it is clear that the data are correct, you are ready to analyse the data and for- mulate any identified health problems—the next phase of the process of care.

advanced practice roles perform comprehensive physical assessments similar to their doctor colleagues, which iden- tify health and illness states, and then recommend or prescribe appropriate follow-up care. In any case, all nurses and midwives conduct selected aspects of physical assess- ment for their purposes. The nursing and midwifery physical assessment focuses on both the person’s illness and functional abilities. For example, if a neurological deficit is present, the nurse or midwife is concerned with identifying how this deficit affects the person’s reasoning and sensorimotor abilities. Another example is if a person who has had a cerebrovascu- lar accident (stroke) is examined to determine their ability to comprehend and communicate information and execute the tasks of everyday life. The purposes of the nursing and midwifery physical assessment include the appraisal of health status, the identi- fication of health problems and the establishment of a database for care interventions. It also allows the nurse or midwife to work with the person to identify strengths and weaknesses that need to be incorporated into the plan of care. See Chapter 30 for a detailed description of physical assessment skills. Nurses and midwives practising in different settings may use different physical health assessment techniques for dif- ferent purposes. Nurses in the coronary care unit use sophisticated, high-technology assessment techniques, whereas nurses in a rehabilitation centre use a wide range of physical assessment skills that focus on identifying func- tional and non-functional response patterns to disabilities. The physical health assessment involves the examination of all body systems in a systematic manner, commonly using a head-to-toe framework (Table 15-1). Four methods are used to collect data during a physical assessment: inspection, palpation, percussion and auscultation. Nurses and midwives may also use physical assessment skills to evaluate selected body systems. These techniques and the basic skills for physical assessment are described in Chapter 30. Problems related to data collection Common problems encountered during data collection include inappropriate organisation of the database, omis- sion of pertinent data, inclusion of irrelevant or duplicate data, erroneous or misinterpreted data, failure to establish rapport and partnership, recording an interpretation of data rather than observed behaviour, and failure to update the database. Table 15-4 describes possible causes and remedies for such problems. DATA VALIDATION Validation is the act of confirming or verifying. The purpose of validating is to keep data as free from error, bias and misinterpretation as possible. Validation is an important part of the assessment phase because invalid information can lead to inappropriate care.